Efficacy and Safety of Autologous Fat Transfer in Facial Reconstructive Surgery: A Systematic Review and Meta-analysis

Using ChatGPT to write a literature review on autologous fat grafting

BACKGROUND

ChatGPT is a large language model (LLM) that has been proposed as a scientific writing tool, though its ethical use remains a highly debated topic within the academic community. This article defines the strengths and weaknesses of ChatGPT in writing a plastic surgery literature review and describes proper methodologies for optimizing GPT-generated output.

METHODS

ChatGPT-4o was prompted to brainstorm topics for a literature review on plastic surgery. Autologous fat grafting was chosen and ChatGPT generated each section of the literature review with citations, which were subsequently evaluated for accuracy. The ability of medical professionals to discriminate between a ChatGPT-generated and published fat grafting abstract was assessed.

RESULTS

ChatGPT successfully conceived and performed a literature review on autologous fat grafting. The model performed well in outline creation, article summarization, and editing content. It generated a professional review of fat grafting, though its claims were generalized, not completely factual, and lacked accurate citations. ChatGPT provided 21 citations, 5 of which correctly referenced a real article. Eight contained errors in their publication details, such as publication dates and author lists. The remaining 8 were unable to be found in PubMed (hallucinated). Medical professionals were unable to distinguish ChatGPT-generated material from a published abstract.

CONCLUSIONS

With appropriate vigilance, ChatGPT may be cautiously used as a writing assistant throughout the literature review process; however, authors must verify all scientific claims and citations. ChatGPT's greatest limitation remains its tendency to hallucinate, which undermines the reliability of a generated manuscript and perpetuates inaccurate information.

Characterization of Fat Used for the Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty

Septorhinoplasty (SRP) is one of the most common aesthetic procedures worldwide. A thin or scarred soft tissue envelope, especially in the context of secondary SRP, can lead to unpredictable scarring, shrinkage, and discoloration of the skin. Other than the careful preparation of the soft tissue mantle, no gold standard exists to minimize the above-mentioned risks. Our aim was to create a thin "separation layer" between the nasal bridge (osseous and cartilaginous) and the skin envelope by autologous fat transfer with the addition of platelet-rich fibrin (PRF) to conceal small irregularities, to improve the quality of the skin soft tissue mantle, and to optimize the mobility of the skin. We report 21 patients who underwent SRP on a voluntary basis. All patients had either thin skin and/or revision SRP with scarring. Macroscopic fat harvested from the periumbilical or rib region was minced and purified. PRF was obtained by centrifugation of autologous whole blood samples and mixed with the fat to form a graft, which was then transferred to the nasal dorsum. Postoperative monitoring of graft survival included sonography and magnetic resonance imaging (MRI) of the nose. The harvested adipose tissue was also analyzed in vitro. In the postoperative follow-up after 1 year, survival of the adipose tissue was demonstrated in all patients by both sonography and MRI. The in vitro analysis showed interindividual differences in the quantity, size, and quality of the transplanted adipocytes. Camouflage of the nasal bridge by using adipose tissue was beneficial for the quality of the skin soft tissue mantle and hence represents a good alternative to known methods. Future aims include the ability to assess the quality of adipose tissue to be transplanted based on clinical parameters. Level of evidence: N/A.

Ultrasound-Guided Female Equilibrated Minimal Muscularization and Enhancement (U-Femme)

Background

High-definition liposculpture (HDL) has undergone significant evolution since its initial description, with the goal of achieving more natural outcomes and a muscular-defined appearance. The introduction of intramuscular fat grafting has enhanced contouring capabilities, with its applications extending to various muscle groups. Subperiosteal fat grafting efficacy and safety are well-established in facial surgery.

Objectives

Describe the technique of combining ultrasound (US)-guided subperiosteal lipoinjection of the anterior superior iliac spine (bikini bridge) plus intramuscular fat grafting of the internal oblique muscles with HDL.

Methods

A retrospective cohort study was conducted across different specialized plastic surgery centers. Adult patients who underwent bikini bridge and dynamic definition liposculpture were included. All patients were informed of the innovative use of the technique and consented to participate. Descriptive statistical analysis was performed to summarize the variables.

Results

A total of 105 consecutive patients were included for analysis. Patients were mostly females (86.7%) plus 14 male patients (13.3%) who were in the gender reassignment process. Mean age was 34.3 years (standard deviation [SD] 8.7 years) and the median BMI was 22.9 kg/m2 (SD 2.74 kg/m2). All patients underwent fat grafting the iliac spines + the oblique muscles as an additional procedure to HDL. Median volume of fat injected was 15 cc (interquartile range 12 cc) for the iliac spines and 40 cc for the internal obliques. No major complications were reported.

Conclusions

The US-guided intramuscular and subperiosteal fat grafting of the abdomen is a safe and reproducible procedure, resulting in a harmonious and athletic appearance with natural-looking outcomes, high satisfaction, and a very low rate of complications.

Level of Evidence 4 Therapeutic

Role of mesenchymal cells in enhancing cosmetic outcomes for autologous augmented fat transfers for facial rejuvenation and reconstructive surgery

In recent years, autologous fat transfer (AFT) has gained popularity for reconstructive and cosmetic procedures due to its minimally invasive nature and natural-looking results. However, limitations such as unpredictable fat resorption and safety concerns persist. To address these issues, researchers have explored incorporating adipose-derived stromal cells (ADSCs) into fat grafts. Enriching fat grafts with ADSCs, often through stromal vascular fraction (SVF), shows promise in regenerative medicine, though their effectiveness remains debated. Some studies suggest no significant difference in outcomes, while others indicate that ADSCs are more effective in larger-volume grafts. This implies that ADSC-enriched grafts might achieve similar results to traditional methods, with volume retention being a crucial success indicator. Given that these cosmetic procedures impact body image and self-confidence, innovative techniques like ADSC-enriched grafts are crucial for improving clinical outcomes. ADSCs are favoured for their abundance in adipose tissue and wound healing properties, which enhance cosmetic results. Patients receiving ADSC-enriched grafts show increased collagen, elastin, and CD31 levels, and better graft survival compared to those with traditional fat grafting, reducing the need for repeat procedures. Recent applications in patients with fibrotic facial deformities have demonstrated positive outcomes both cosmetically and psychologically. This mini-review evaluates the efficacy and benefits of ADSC-enriched AFT for facial rejuvenation and reconstruction, focusing on graft retention and overall procedural outcomes.

Decoding the Implications of Glucagon-like Peptide-1 Receptor Agonists on Accelerated Facial and Skin Aging

Following the advent of glucagon-like peptide-1 receptor agonists (GLP-1RAs), subsequent unintended effects such as accelerated facial aging and altered skin health have been noted. This review delves deeper into the causative underlying mechanisms and provides insights into the intricate relationship between GLP-1RAs, adipose tissue, and premature facial aging, thereby highlighting the need for a nuanced understanding of their effects on facial alterations and skin health. Studies exploring the potential effects of GLP-1RAs on facial alterations and offering insights into the possible underlying mechanisms, causes, and clinical implications were included. The accelerated facial aging and altered skin health observed in GLP-1RA patients appears to be multifactorial, involving loss of dermal and subcutaneous white adipose tissue, and altered proliferation and differentiation of adipose-derived stem cells (ADSCs), and impacts on the production and secretion of hormonal and metabolic factors. These changes compromise the structural integrity and barrier function of the skin and may lead to diminished facial muscle mass, further exacerbating the appearance of aging. The insights presented call for a paradigm shift in the clinical management of facial changes induced by GLP-1RAs, with a focus on treatment strategies aimed at targeting ADSC stimulation. These include autologous fat transfers to reintroduce cells rich in ADSCs for rejuvenation, composite fat grafting combining autologous fat with/without stromal vascular fraction, and the strategic use of soft tissue fillers for volume restoration and biostimulation. This review highlights the potential role of GLP-1RAs in modulating adipose tissue dynamics, thereby contributing to accelerated aging through metabolic, structural, and hormonal pathways.

LEVEL OF EVIDENCE: 5

Exploring Superselective Intraarterial Thrombolysis for Autologous Fat Injection-Induced Vision Loss

BACKGROUND

Intravascular injection represents the most severe complication in fat transplantation procedures. Currently, the prognosis for patients who suffer from blindness due to fat transplantation-induced ocular vascular occlusion is far from optimistic.

OBJECTIVES

The aim of this study was to explore and evaluate the efficacy and safety of arterial thrombolysis in the treatment of ocular vascular occlusion caused by fat transplantation.

METHODS

We analyzed the data of 12 patients who underwent intraarterial thrombolysis and conservative treatments for facial autologous fat grafting-associated ocular vascular occlusion. Among the cases, there were 6 instances of ophthalmic artery embolism and 6 cases of central retinal artery occlusion. All patients suffered with sudden blindness, sometimes accompanied by eye pain, ptosis, strabismus, skin necrosis at the injection site, or cerebral microinfarction. They received symptomatic conservative treatments and intraarterial thrombolysis, encompassing mechanical vessel recanalization, vessel dilation, and dissolution of thrombus constituents.

RESULTS

Following intraarterial thrombolysis, a noteworthy improvement in the blood flow of both the main trunk and peripheral branches of the ophthalmic artery was observed in the majority of patients when contrasted with their pretreatment status. One patient experienced a headache intraoperatively, while no significant discomfort was reported by the remaining patients. After conservative treatments and intraarterial thrombolysis, all patients experienced improvement in ocular symptoms, skin necrosis, and cerebral infarction. Three patients demonstrated improvement in visual acuity. These patients had surpassed the recommended time window for treatment, yet the occlusion of the ophthalmic artery was not complete.

CONCLUSIONS

Intraarterial thrombolysis combined with conservative treatments achieves early perfusion and is expected to promote visual recovery. Hospitals that possess the necessary treatment capabilities are encouraged to establish this therapeutic pathway.

Augmentation Rhinoplasty and Centrofacial Lipofilling: Our Experience (ARCL)

Introduction: Augmentation rhinoplasty traditionally represents a serious challenge for plastic surgeons. The association with centrofacial lipofilling is a great approach to achieve harmonious, aesthetic results. The aim of this article is to describe our personal association between Augmentation Rhinoplasty and Centrofacial Lipofilling (ARCL) in non-Caucasian patients. Materials and Methods: In this study, we retrospectively reviewed patients treated with ARCL at our institution between January 2019 and December 2023. We described our personal approach and technique. At a minimum follow-up time of one year, post-operative pictures were taken, and patients were reassessed, evaluating aspects such as global symmetry, shape and contour of the nose, and facial harmony and rejuvenation; finally, patients' satisfaction was investigated according to the ROE questionnaire and the modified S-GAIS. Results: A total of 307 patients were included in the study. They reported a significant satisfactory aesthetic result in nasal image and facial harmony, as the mean postoperative ROE and S-GAIS score show. None of the grafts extruded or collapsed. Wounds healed without reported major infection. Conclusions: This study has demonstrated that ARCL is a safe approach that contributes to improve functional and aesthetic outcomes, has a high patient satisfaction rate, and limited post-operative complications.

Enhancing Philtrum Morphology Using Fat Grafting Combined with Percutaneous Rigottomy in Repaired Unilateral Cleft Lip

BACKGROUND

Improving the philtrum morphology of patients with a secondary cleft lip deformity has been a challenge in cleft care. Combining fat grafting with percutaneous rigottomy has been advocated for treatment of volumetric deficiency associated with a scarred recipient site. This study assessed the outcome of synchronous fat grafting and rigottomy for improvement of cleft philtrum morphology.

METHODS

Consecutive young adult patients ( n = 13) with a repaired unilateral cleft lip who underwent fat grafting combined with rigottomy expansion technique for enhancement of philtrum morphology were included. Preoperative and postoperative three-dimensional facial models were used for three-dimensional morphometric analyses including philtrum height, projection, and volume parameters. Lip scar was qualitatively judged by a panel composed by two blinded external plastic surgeons using a 10-point visual analogue scale.

RESULTS

Three-dimensional morphometric analysis revealed a significant (all P < 0.05) postoperative increase of the lip height-related measurements for cleft philtrum height, noncleft philtrum height, and central lip length parameters, with no difference ( P > 0.05) between cleft and noncleft sides. The postoperative three-dimensional projection of the philtral ridges was significantly ( P < 0.001) larger in cleft (1.01 ± 0.43 mm) than in noncleft sides (0.51 ± 0.42 mm). The average philtrum volume change was 1.01 ± 0.68 cm 3 , with an average percentage fat graft retention of 43.36% ± 11.35%. The panel assessment revealed significant ( P < 0.001) postoperative scar enhancement for the qualitative rating scale, with mean preoperative and postoperative scores of 6.69 ± 0.93 and 7.88 ± 1.14, respectively.

CONCLUSION

Synchronous fat grafting and rigottomy improved philtrum length, projection, and volume and lip scar in patients with repaired unilateral cleft lip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Multicenter Pilot Study of a Novel Allograft Adipose Matrix in Malar and Prejowl Volume Restoration

Background

Allograft adipose matrix (AAM) offers a novel, off-the-shelf, and readily available natural option in the treatment of facial soft tissue volume and reconstructive deficits. AAM is a natural soft tissue supplement or replacement that can support cushioning and volume correction. A prospective multicenter pilot study evaluated AAM in facial volume restoration.

Methods

Eleven women (mean age of 55.8 ± 10.9 y) with midface volume deficit were followed up for 24 weeks after AAM treatment in this institutional review board-approved multicenter pilot study. The clinical safety and efficacy of the AAM treatment were evaluated using clinical scales and three-dimensional quantitative facial photography.

Results

AAM was safe to address facial volume deficits, with minor site-related adverse events and discomfort that resolved within 2-4 weeks. Observations also revealed facial volume improvements throughout the study with 91% positive responders. At week 24, the subject facial satisfaction scores revealed an 86% increase compared to baseline, along with a statistically significantly improved midface fullness compared to baseline.

Conclusion

AAM offers a natural and safe option for midface volume restoration and supports overall satisfaction and volume improvements.

Lipotranferences in post neurosurgical esthetic defects

Background

There are numerous procedures in which, beyond adequate manipulation of the temporalis muscle and cranial closure, patients may present bone and muscle defects due to atrophy and consequent facial asymmetry, causing psychological discomfort and functional deterioration. The objective of our work is to combine the knowledge of plastic surgery and apply it to cranial reconstructions with fat transfers in post-neurosurgical patients, analyzing its results.

Methods

During the year 2022, 45 fat transfer procedures were performed for the correction of craniofacial defects, of which 29 were female and 16 were male. All had a surgical history of pterional craniotomies and their variants, orbitozygomatic and transzygomatic approaches, with the consequent volume deficit.

Results

The procedure was performed on an outpatient basis, with local anesthesia, and in an average time of 30-40 min. The lower hemiabdominal region was used as the donor area, processing the fat using the decantation technique and injecting it into the receptor area at the craniofacial level. The patients tolerated the procedure adequately without intraoperative complications or superadded events.

Conclusion

Fat transfer is a minimally invasive, effective, and cost-effective technique that plastic surgery offers us to implement in post-neurosurgical patients, as it achieves natural results that stand the test of time.

Quantifying outcomes of autologous fat transplantation in different facial deformities: A systemic review and meta-analysis

BACKGROUND

Autologous fat transplantation has become a common treatment for facial deformities. However, facial deformities are the result of complex diseases with different causes, and there has been no review on the effectiveness of autologous fat transplantation for facial deformities of different aetiologies.

METHODS

A systematic literature search of the Web of Science, Embase, and Medline Ovid databases was performed up to December 2022. Two investigators independently performed screening and data extraction according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by a meta-analysis using random-effects model for surgeon and patient satisfaction, facial symmetry, and complication rates. Twelve-month postoperative fat graft retention was estimated by meta-regression.

RESULTS

Thirty-one studies met the criteria, including 13 case series studies, 14 cohort studies, and four randomized clinical trials, with a total of 1572 patients. Follow-up visits within 6-12 months were performed in most of the studies. The results of the meta-analysis showed high overall surgeon satisfaction of 97% (95% CI: 92%-100%) and patient satisfaction of 95% (95% CI: 89%-99%), with a low complication rate of 3.4% (95% CI: 1.9%-5.9%). At 12 months postoperatively, a lower retention rate of 43% (95% CI: 28%-58%) was estimated in cases of acquired atrophic deformities compared with 64% (95% CI: 57%-71%) in cases of mixed deformities. Overall, autologous fat transplantation improved facial symmetry by 13% (95% CI: 8.4%-18%).

CONCLUSION

Autologous fat transplantation is generally a safe and effective procedure that can compensate for facial volume deficits and improve facial symmetry but may be less effective in cases of acquired atrophic facial deformities.

Stem Cell Enriched Fat Grafts versus Autologous Fat Grafts in Reconstructive Surgery: Systematic Review and Meta-Analysis

OBJECTIVE

To compare the outcomes of stem cell-enrichment fat grafting (SCEFG) versus autologous fat grafting (AFG) for reconstructive purposes.

METHODS

A systematic review and meta-analysis was performed as per the preferred reporting items for systematic reviews and meta-analyses. Guidelines and a search of electronic information was conducted to identify all Randomised Controlled Trials (RCTs), case-control studies and cohort studies comparing the outcomes of SCEFG versus AFG. Volume retention, fat necrosis, cancer recurrence, redness and swelling, infection, and cysts were primary outcome measures. Secondary outcome measures included patient satisfaction post-surgery, scar assessment, operation time and number of fat grafting sessions. Fixed and random effects modelling were used for the analysis.

RESULTS

16 studies enrolling 686 subjects were selected. Significant differences between the SCEFG and AFG groups were seen in mean volume retention (standardised mean difference = 3.00, P < 0.0001) and the incidence of redness and swelling (Odds Ratio [OR] = 441, P = 0.003). No significant difference between the two groups in terms of fat necrosis (OR = 2.23, P = 0.26), cancer recurrence (OR = 1.39, P = 0.58), infection (OR = 0.30, P = 0.48) and cysts (OR = 0.88, P = 0.91). For secondary outcomes, both cohorts had similar results in patient satisfaction, scar assessment and number of fat grafting sessions. Operation time was longer for the intervention group.

CONCLUSIONS

SCEFG offers better outcomes when compared to AFG for reconstructive surgery as it improves the mean volume retention and does not worsen patient satisfaction and surgical complications except for self-limiting redness and swelling. Further clinical trials are recommended to support this argument and validate the use of SCEFG in clinical practice.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Stem Cell-Enriched Fat Grafts Versus Autologous Fat Grafts for Facial Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to compare the outcomes of stem cell-enrichment fat grafting versus routine fat grafting for facial reconstruction purposes.

METHODS

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines and a search of electronic information was conducted to identify all randomized controlled trials, case control studies, and cohort studies comparing the outcomes of stem cell enrichment fat grafting versus routine fat grafting for facial reconstruction purposes. Volume retention and infection rate were primary outcome measures. Secondary outcome measures included patient satisfaction postsurgery, redness and swelling, fat necrosis, cysts, as well as operation time. Fixed and random effects modeling was used for the analysis.

RESULTS

Eight studies enrolling 275 subjects were selected. There was a significant difference between the stem cell enrichment fat grafting and routine grafting groups in terms of mean volume retention (standardized mean difference, 2.49; P < 0.00001). However, there was no significant difference between the 2 groups in the rate of infection (odds ratio, 0.36; P = 0.30). For all secondary outcomes, the intervention group had similar results compared with the control group except for the operation time, which was shorter in the latter.

CONCLUSIONS

Stem cell-enriched fat grafting is a superior option when compared with the routine fat grafting for facial reconstruction surgery because it improves the mean volume retention and does not worsen patient satisfaction and surgical complications.

Outcomes Following Autologous Fat Grafting in Patients with Sequelae of Head and Neck Cancer Treatment

A single-center retrospective study was designed to assess the outcomes of autologous fat grafting for improving surgery- and radiotherapy-related sequelae in 40 patients with head and neck cancer. All patients underwent surgical resection of primary tumors and radiotherapy (50-70 Gy) and were followed over 12 months after fat grafting. Eligibility for fat grafting procedures included complete remission after at least 3 years of oncological treatment. The cervical and paramandibular regions were the most frequently treated areas. Injected fat volumes ranged between 7.5 and 120 mL (mean: 23 mL). Esthetic improvement was obtained in 77.5% of patients, being significant in 17.5%, and functional improvement in 89.2%, being significant in 29.7% of patients. Minor complications occurred in three patients. There was a high degree of satisfaction regarding esthetic improvement, global satisfaction, and 92.5% of patients would recommend the procedure. This study confirms the benefits of fat grafting as a volumetric correction reconstructive strategy with successful cosmetic and functional outcomes in patients suffering from sequelae after head and neck cancer treatment.

Metabolic effects of lipectomy and of adipose tissue transplantation

OBJECTIVE

The goal of this study was to review the metabolic effects of fat transplantation.

METHODS

Fat (adipose tissue [AT]) transplantation has been performed extensively for many years in the cosmetic reconstruction industry. However, not all fats are equal. White, brown, and beige AT differ in energy storage and use. Brown and beige AT consume glucose and lipids for thermogenesis and, theoretically, may provide greater metabolic benefit in transplantation. Here, the authors review the metabolic effects of AT transplantation.

RESULTS

Removal of subcutaneous human AT does not have beneficial metabolic effects. Most studies find no benefit from visceral AT transplantation and some studies report harmful effects. In contrast, transplantation of inguinal or subcutaneous AT in mice has positive effects. Brown AT transplant studies have variable results depending on the model but most show benefit.

CONCLUSIONS

Many technical improvements have optimized fat grafting and transplantation in cosmetic surgery. Transplantation of subcutaneous AT has the potential for significant metabolic benefits, although there are few studies in humans or using human AT. Brown AT transplantation is beneficial but not readily feasible in humans thus ex vivo "beiging" may be a useful strategy. AT transplantation may provide clinical benefits in metabolic disorders, especially in the setting of lipodystrophy.

Supplementation of Facial Fat Grafting to Increase Volume Retention: A Systematic Review

BACKGROUND

For decades, facial fat grafting has been used in clinical practice for volume restoration. The main challenge of this technique is variable volume retention. The addition of supplements to augment fat grafts and increase volume retention has been reported in recent years.

OBJECTIVES

The aim of this systematic review was to investigate which supplements increase volume retention in facial fat grafting as assessed by volumetric outcomes and patient satisfaction.

METHODS

Embase, Medline, Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to November 30, 2020. Only studies assessing volume after facial fat grafting with supplementation in human subjects were included. Outcomes of interest were volume or patient satisfaction. The quality of the studies was assessed with the Effective Public Health Practice Project tool.

RESULTS

After duplicates were removed 3724 studies were screened by title and abstract. After reading 95 full-text articles, 27 studies were eligible and included for comparison. Supplementation comprised of platelet-rich plasma, platelet-rich fibrin, adipose tissue-derived stromal cells or bone marrow-derived stromal cells, cellular or tissue stromal vascular fraction, or nanofat. In 13 out of 22 studies the supplemented group showed improved volumetric retention and 5 out of 16 studies showed greater satisfaction. The scientific quality of the studies was rated as weak for 20 of 27 studies, moderate for 6 of 27 studies, and strong for 1 study.

CONCLUSIONS

It remains unclear if additives contribute to facial fat graft retention and there is a need to standardize methodology.

LEVEL OF EVIDENCE: 4

Facial Fat Grafting (FFG): Worth the Risk? A Systematic Review of Complications and Critical Appraisal

Introduction: Autologous fat is ideal soft tissue filler. It is easily accessible, biocompatible, cheap, and it provides both volume augmentation and skin quality improvement. Fat grafting has been used since 1893, but it has only gained widespread popularity since the development of modern liposuction by Colemann and Illouz in the 1980s. Every year more than half a million facial fat grafting procedures are carried out worldwide and the trend is rapidly increasing. Overall, general complications associated with facial fat grafting are assumed to be around 2%. Is that true? Material and Methods: Until July 2021, a systematic search of the literature was performed interrogating PubMed search engines. The following algorithm was used for the research: (fat graft OR lipofilling) AND face AND complications. Exclusion criteria applied hierarchically were review articles, not reporting recipient site complications; not in English and paediatric population. Abstracts were manually screened by LS, GS, JM and PDS separately and subsequently matched for accuracy. Pertinent full-text articles were retrieved and analysed and data were extracted from the database. The flow chart of article selection is described following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: In total, 462 papers were identified by PubMed search. A total of 359 were excluded: 38 papers were not in English, 41 were review articles, 279 articles did not report recipient site complications and 1 was not on human subjects. Average complication rate ranged from 1.5% to 81.4%. A total of 298 adverse events were identified: 40 (13.4%) intravascular injections, 13 (4.3%) asymmetry, 57 (19.1%) irregularities, 22 (7.4%) graft hypertrophy, 21 (7%) fat necrosis, 73 (24.5%) prolonged oedema, 1 (0.3%) infection, 6 (2%) prolonged erythema, 15 (5%) telangiectasia and 50 (16.8%) cases of acne activation. Conclusions: FFG related side effects could be resumed in three categories: severe, moderate, and minor. Severe (13.4%) side effects such as intravascular injection or migration require neurological or neurosurgical management and often lead to permanent disability or death. Moderate (38.3%) side effects such as fat hypertrophy, necrosis, cyst formation, irregularities and asymmetries require a retouch operation. Minor (48.3%) side effects such as prolonged oedema or erythema require no surgical management. Despite the fact that the overall general complication rate of facial fat grafting is assumed to be around 2%, the real complication rate of facial fat grafting is unknown due to a lack of reporting and the absence of consensus on side effect definition and identification. More RCTs are necessary to further determine the real complication rate of this procedure.

The General Registry of Autologous Fat Transfer: Concept, Design, and Analysis of Fat Grafting Complications

BACKGROUND

The American Society of Plastic Surgeons and The Plastic Surgery Foundation launched GRAFT, the General Registry of Autologous Fat Transfer, in October of 2015. This web-accessible registry addresses the need for prospective and systematic data collection, to determine the rates of unfavorable outcomes (complications) of fat grafting. Understanding and avoiding the factors that lead to complications can help establish safe practices for fat grafting.

METHODS

Data collected between October of 2015 and November of 2019 were summarized for age, sex, indications, processing techniques, and fat graft volume. Rates of complications for fat grafting to various anatomical areas were calculated.

RESULTS

The General Registry of Autologous Fat Transfer collected data on 7052 fat grafting procedures from 247 plastic surgery practices. The mean age of the patients in the registry was 51 years (range, 1 to 89 years), 94 percent were female, and 64 percent of the procedures were for aesthetic indications. Whereas the overall complication rate was low (5.01 percent), the complication rates for fat grafting to the breast and buttocks (7.29 percent and 4.19 percent, respectively) were higher than those for face and other areas (1.94 percent and 2.86 percent, respectively). Oil cysts (2.68 percent) and infections (1.64 percent) were the most common complications of breast fat grafting, whereas seroma (1.84 percent) and palpable mass (1.33 percent) were most common for fat grafting to buttocks. Palpable mass (0.54 percent) and infections (0.54 percent) were most common for fat grafting to face.

CONCLUSIONS

The General Registry of Autologous Fat Transfer provides a valuable tool for prospective tracking of fat grafting techniques and complications. Data collected in the registry show low rates of complications for all recipient areas treated with fat grafting.

CLINICAL RELEVANCE STATEMENT

GRAFT collects real world data on complications of autologous fat grafting procedures. The data collected over 4 years shows low rates of complications for fat grafting. The benchmarking tools available in GRAFT can help enhance techniques and safety of fat grafting.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Superior Ophthalmic Vein Embolism Following Forehead Augmentation with Autologous Fat Injection

Background

Facial rejuvenation and reconstruction with autologous fat injection are a common and effective procedure used worldwide. Most surgeons and patients are satisfied with the favorable outcomes. However, catastrophic complications from arterial and venous occlusion resulting in visual loss and stroke may occur.

Case presentation

We herein report a case of isolated venous occlusion from fat embolism. The patient developed acute painful proptosis and blurred vision of her right eye while undergoing an esthetic autologous fat injection into her forehead. Based on her clinical manifestations and radiologic findings, the patient was diagnosed with superior ophthalmic vein occlusion. Symptomatic and supportive treatments were given. Spontaneous clinical improvement occurred without secondary complications. Therefore, the initially planned endovascular therapy with transfemoral transvenous embolectomy of the right superior ophthalmic vein was canceled.

Conclusions

Facial augmentation with autologous fat injection can cause superior ophthalmic vein embolism. Surgeons should therefore perform this procedure very cautiously. Prompt ophthalmological evaluation and proper management are important for improving clinical outcomes.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Ear reconstruction research using animal models: The effect of fat grafting on costal cartilage stents

OBJECT

For congenital microtia patients with a depressed mastoid area, it is unclear whether autologous fat grafting to fill the depressed area of the cheek will affect the survival of the subsequent grafted costal cartilage stent. An animal model was used for in vivo research to provide guidance for clinical applications.

METHODS

Autologous costal cartilage was implanted in nude mice. Fat samples were collected at different time points and histological examination performed to analyze the activity of chondrocytes and the deposition of the chondrocyte matrix.

RESULTS

This nude mouse fat transplantation model study showed that there were statistical differences in chondrocyte viability between the fat filling group and the control group, but there was no statistical difference in the effect on collagen content.

CONCLUSION

Transplanting fat reduces the viability of chondrocytes, but has little effect on collagen matrix deposition.

Autologous Fat Transfer Harvest-site Complications: Incidence, Risk Factors, and Management

PURPOSE

Autologous fat transfer is an effective tool for volume restoration to the aging face. Although numerous reports exist regarding injection site complications, there is limited data on donor-site morbidity in the cosmetic surgery literature.

METHODS

This study is a large-scale retrospective review to determine incidence of fat harvest-site complications, identify risk factors, and describe management strategies. Records of all patients who underwent autologous fat harvesting and facial grafting at a single oculofacial plastic surgery practice from 2010 to 2019 were reviewed. Patient demographics and clinical data were collected and assessed. A statistical analysis was performed using a two-tailed T-test with p values of <0.05 considered significant.

RESULTS

Four-hundred sixteen patients were followed for an average of 6.2 months postoperatively. There was an overall 5.5% harvest-site complication rate. There was no correlation of harvest-site complications with gender (p = 0.249) or age (p = 0.881). Harvest location did not significantly correlate with complication rate. The most common complications were contour irregularities, prolonged induration, and prolonged erythema. Low body mass index was associated with higher complication rate (p = 0.003), even when excluding those patients with contour irregularities (p = 0.001). Various treatment modalities were used to manage donor-site morbidity with consistent improvement.

CONCLUSIONS

Autologous fat transfer used for facial volume augmentation has low donor-site morbidity. Minor harvest-site complications occur more commonly in patients with low body mass index, irrespective of age, gender, or fat source.

The Impact of N-Acetylcysteine on Autologous Fat Graft: First-in-Human Pilot Study

BACKGROUND

Our goal was to determine whether N-acetylcysteine (NAC) administered to the tumescent solution can reduce oxidative stress and increase autologous fat graft (AFG) viability.

METHODS

The study included 15 women with a mean age of 31.8 years (range 23-39 years) who underwent breast asymmetry correction with AFG harvested from both thighs. One thigh was infiltrated with a standard tumescent fluid (control graft) and other with a NAC-enriched tumescent fluid (NAC-treated graft). Each participant had breast MRI imaging before and 6 months after the procedure. Also, adipose tissue samples from each graft were subjected to biochemical analysis, flow cytometric assay and qRT-PCR to determine the markers of oxidative stress, angiogenesis and adipogenesis.

RESULTS

Concentration and activity of superoxide dismutase in the NAC-treated grafts turned out to be significantly higher than in the control grafts, in both fresh (p = 0.041 and p = 0.023, respectively) and frozen samples (p = 0.004 and p = 0.003, respectively). The level of nitric oxide in frozen samples from the control grafts was significantly higher than in the NAC-treated grafts (p = 0.009). iNOS was the only qRT-PCR target showing significant intergroup differences, with higher transcription levels observed in the control grafts (p = 0.027). Breast volumetric analysis demonstrated that the NAC-treated group had a 12.19% lower resorption rate than the control group, although it was found to be statistically insignificant (p = 0.149). No postoperative complications were observed during a 6-month follow-up.

CONCLUSIONS

Some results of this study are promising. Further studies on larger groups are needed to determine NAC impact on AFG.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

TRIAL REGISTRY NAME

The Impact of N-Acetylcysteine on Volumetric Retention of Autologous Fat Graft for Breast Asymmetry Correction.

REGISTRATION IDENTIFICATION NUMBER

NCT03197103. URL FOR THE REGISTRY: https://clinicaltrials.gov/ct2/show/NCT03197103?term=acetylcysteine&amp;rank=6.

Autologous fat grafting in the face and neck: Multinational trends and knowledge of the safety, applications, and indications considering oncologic risk potential

BACKGROUND

Autologous fat grafting (AFG) is evolving in both aesthetic and reconstructive applications, since the body of evidence for its use has expanded. The earliest controversies were evident in lipofilling for oncological breast reconstruction, and to this day, some countries do not allow it for fear of inducing tumourigenesis in an oncologically ablated field.

METHODS

We sought to review contemporary harvesting and processing techniques for AFG in the craniofacial region, therefore distributed a survey to evaluate the clinical impact of oncological risk across four European countries.

RESULTS

We found no significant geographical differences between the German-speaking and the English groups concerning their harvesting and processing technique. Half of our respondents discuss the possibility of pro-oncologic behavior of AFG.

CONCLUSION

AFG harvesting and processing techniques do not considerably vary by geography. Further studies should evaluate oncologic risk potential of AFG in head and neck tumor sites, especially because there is no excellent article regarding this phenomenon.Level of Evidence: V.

Human Adipose-Derived Stem/Stromal Cells Promote Proliferation and Migration in Head and Neck Cancer Cells

Simple Summary

Fat grafts obtained from a minimal invasive liposuction device contain multipotent stem cells termed adipose-derived stem/stromal cells (ASCs). ASCs can be used for their proposed wound healing relevant characteristics, including for tissue defects in cancer patients. For head and neck cancers, little is known about the effects of ASCs on tumor cells. Using supernatants of ASCs from five patients in different functional experiments, this study aimed to investigate how ASCs influence tumor growth, invasive properties, and neoangiogenesis. The data show that all mentioned characteristics are promoted by fat graft stem cells in vitro in head and neck cancer cell lines. Although clinical relevance of these in vitro findings is unclear, due to the lack of in vivo and clinical data, fat grafts should be used cautiously and complete removal of tumor should be ensured before augmentation in head and neck cancer patients is performed.

Abstract

Human adipose-derived stem/stromal cells (ASCs) are increasingly used as auto-transplants in regenerative medicine to restore tissue defects or induce wound healing, especially in cancer patients. The impact of ASCs on squamous cell carcinoma of the upper aerodigestive tract (UAT) including head and neck and esophageal squamous cell carcinoma (HNSCC and ESCC) is not yet fully understood. ASCs were cultured from subcutaneous, abdominal lipoaspirates of five patients, who received auto-transplants to the head and neck. Supernatants were tested for paracrine effects in functional in vitro assays of proliferation of HNSCC tumor cell line FaDu and ESCC cell line Kyse30, and their cell migration/invasion capacities in Boyden chambers, in addition to endothelial tube formation assay using human umbilical vein endothelial cells (HUVECs). All ASC-derived supernatants enhanced proliferation of FaDu cells, invasive migration, and tube formation by HUVECs, compared to controls. Of five patients’ lipoaspirates, ASC-derived supernatants of four patients increased proliferation and invasive migration in Kyse30 cells. The data suggests that ASCs can promote tumor cell proliferation, invasiveness, and neo-angiogenesis in these tumor cell lines of the UAT and HUVEC in a paracrine manner. Although clinical studies on the subject of oncological safety are still needed, these findings emphasize the importance of complete tumor removal before ASCs are used in the head and neck.

Assessing Clinical Outcomes in Autologous Fat Grafting: A Current Literature Review

Autologous fat grafting, first described in the 1890s, has since undergone many modifications to optimize safety and efficacy. These changes have resulted in the technique that we now consider standard of care, one that is applied to reconstruction and cosmetic enhancement of the breast and the face both independently and in conjunction with surgical treatment. There is a growing body of evidence that this application has positive outcomes for patient satisfaction, surgeon satisfaction, and overall aesthetic appearance. This article summarizes the body of literature regarding these outcomes, reviews complications of fat grafting in the face and breast, and discusses controversies including radiologic imaging changes and longevity of grafting. Level of Evidence: 4.

Autologous Fat Grafting Does Not Increase Risk of Oncologic Recurrence in the Reconstructed Breast

INTRODUCTION

Autologous fat grafting (AFG) is a popular and effective method of breast reconstruction after mastectomy; however, the oncological safety of AFG remains in question. The aim of this study was to determine whether AFG increases the risk of cancer recurrence in the reconstructed breast.

METHODS

A matched, case-control study was conducted from 2000 to 2017 at the senior author's institution. Inclusion was limited to female patients who underwent mastectomy and breast reconstruction with or without AFG. Data were further subdivided at the breast level. χ analyses were used to test the association between AFG status and oncologic recurrence. A Cox proportional-hazards model was constructed to assess for possible differences in time to oncologic recurrence. The probability of recurrence was determined by Kaplan-Meier analyses and confirmed with log-rank testing.

RESULTS

Overall, 428 breasts met study criteria. Of those, 116 breasts (27.1%) received AFG, whereas 312 (72.9%) did not. No differences in the rates of oncologic recurrence were found between the groups (8.2% vs 9.0%, P < 1.000). Unadjusted (hazard ratio = 1.03, confidence interval = 0.41-2.60, P < 0.957) and adjusted hazard models showed no statistically significant increase in time to oncologic recurrence when comparing AFG to non-AFG. In addition, no statistical differences in disease-free survival were found (P = 0.96 by log rank test).

CONCLUSION

Autologous fat grafting for breast reconstruction is oncologically safe and does not increase the likelihood of oncologic recurrence. Larger studies (eg, meta analyses) with longer follow-up are needed to further elucidate the long-term safety of AFG as a reconstructive adjunct.

Volume Retention After Facial Fat Grafting and Relevant Factors: A Systematic Review and Meta-analysis

BACKGROUND

Autologous fat grafting is common in facial reconstructive and cosmetic surgeries; the most important drawbacks are the high absorption rate and unpredictable volume retention rate. Surgeons usually make clinical judgements based on their own experience. Therefore, this study aimed to systematically and quantitatively review the volume retention rate of facial autologous fat grafting and analyse the relevant influencing factors.

METHODS

A systematic literature review was performed using the Medline, EMBASE, Cochrane Library, and Web of Science databases in October 2019 for articles that reported objectively measured volume retention rates of facial fat grafting. Patient characteristics, fat graft volumetric data, and complications were collected. A meta-analysis using a random-effects model was conducted to pool the estimated fat retention rate. Relevant factors were analysed and reviewed on the basis of subgroups.

RESULTS

We included 27 studies involving 1011 patients with facial fat grafting. The volume retention rate varied from 26 to 83%, with a mean follow-up of 3-24 months. The overall pooled retention rate was 47% (95% CI 41-53%). The volume measurement method significantly influenced the reported retention rate. A trend towards better retention was found for secondary fat grafting procedures and patients with congenital deformities. Only 2.8% of all patients had complications.

CONCLUSION

The exact percentage of facial fat grafts retained is currently unpredictable; the reported rate varies with different estimation methods. This review analysed studies that provided objectively measured volume retention rates, the pooled average percentage of facial fat graft retention (47%, 95% CI 41-53%), and relevant factors.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optimization of the Soft Tissue Envelope of the Nose in Rhinoplasty Utilizing Fat Transfer Combined with Platelet-Rich Fibrin

A thin or damaged skin soft tissue envelope may cause concerns in primary and secondary rhinoplasty. During postoperative healing, unpredictable scarring and contraction may occur and lead to significant aesthetic and trophic sequelae. Besides a meticulous surgical technique, there are no reliable techniques to prevent long-term skin damage and shrinkage. Fat transfer with addition of platelet-rich fibrin (PRF) harbors the possibility of local soft tissue regeneration and skin rejuvenation through growth factors and mesenchymal stem cells. It may also facilitate the creation of a thin fat layer on the dorsum to prevent shrink-wrap forces and conceal small irregularities. The goal is to provide evidence for the feasibility, durability, and beneficial effect of diced macrofat transfer bonded with PRF on the nasal dorsum. We present the technique of fat transfer conjugated with PRF as a nasal dorsal graft. Clinical endpoints were the prevention of trophic disturbances and atrophy at a 1-year postoperative follow-up. We present the skin mobility test as a clinical indicator of a healthy soft tissue envelope. The presented case series consists of 107 rhinoplasties. Fat was harvested in the umbilical or costal region. PRF was created by centrifugation of autologous whole blood samples. Macrofat was diced, cleaned, and bonded with PRF. The compound transplants were transferred to the nasal dorsum. There were no perioperative complications or wound-healing issues. Mean follow-up was 14 months. Clinical inspection showed good skin quality and no signs of shrinkage, marked scarring, or color changes with positive skin mobility test in all patients. Survival of fat was confirmed by ultrasonography and magnetic resonance imaging. Diced macrofat transfer in conjunction with PRF to the nasal dorsum is a feasible and safe method. A beneficial effect on the soft tissue envelope is demonstrated as well as the prevention of shrink-wrap forces.

Fat transfer after parotidectomy: fat resorption rates, aesthetic and functional outcomes of en-bloc fat graft versus lipofilling technique

PURPOSE

Reconstruction of parotidectomy involves the correction of facial contour abnormalities and prevention from Frey Syndrome. Reconstruction of parotidectomy field with autologous fat has not been popular among head and neck surgeons due to unclear predictability of fat resorption rates. The aim of this paper is to compare the fat resorption rates between different fat transfer techniques using radiologic measurements and reviewing the aesthetic and functional outcomes.

METHODS

We retrospectively reviewed medical records of patients, who underwent parotidectomy in Hacettepe University Hospital between 2015 and 2018. The aesthetic and functional outcomes of en-bloc fat graft and lipofilling techniques were compared among themselves, as well as with patients who had no reconstruction, using objective parameters. Fat resorption rates were compared using calculation of fat volumes obtained by MRI scans, 1 year after surgery.

RESULTS

Among 77 patients, 26 underwent reconstruction with en-bloc fat graft (P-EBFG); 21 patients reconstruction with lipofilling technique (P-LFT), whereas 30 patients had no reconstruction of parotidectomy field (P-NR). In three groups, there was no statistically significant difference in mean resected parotid tissue volumes (mean 18 ± 10.8 cm³, p = 0.754). We found a significant difference in decreased presence of Frey Syndrome and increased satisfation rates of cosmetic appearance in P-EBFG and P-LFT, in comparison to P-NR (p < 0.001). There was no significant difference in fat resorption rates between P-EBFG (50.75 + 21.20%) and P-LFT (48.59 + 17.93%) (p = 0.771).

CONCLUSION

Both en-bloc fat graft and lipofilling techniques have been found to be safe and to have similar fat resorption rates for reconstruction after parotidectomy.

Deciphering the Emerging Roles of Adipocytes and Adipose-Derived Stem Cells in Fat Transplantation

Autologous fat transplantation is widely regarded as an increasingly popular method for augmentation or reshaping applications in soft tissue defects. Although the fat transplantation is of simple applicability, low donor site morbidity and excellent biocompatibility, the clinical unpredictability and high resorption rates of the fat grafts remain an inevitable problem. In the sites of fat transplantation, the most essential components are the adipocyte and adipose-derived stem cells (ADSCs). The survival of adipocytes is the direct factor determining fat retention. The efficacy of fat transplantation is reduced by fat absorption and fibrosis due to the inadequate blood flow, adipocyte apoptosis and fat necrosis. ADSCs, a heterogeneous mixture of cells in adipose tissue, are closely related to tissue survival. ADSCs exhibit the ability of multilineage differentiation and remarkable paracrine activity, which is crucial for graft survival. This article will review the recent existing research on the mechanisms of adipocytes and ADSCs in fat transplantation, especially including adipocyte apoptosis, mature adipocyte dedifferentiation, adipocyte browning, ADSCs adipogenic differentiation and ADSCs angiogenesis. The in-depth understanding of the survival mechanism will be extremely valuable for achieving the desired filling effects.

The role of a shelf-ready, human-derived, soft tissue injectable adipose matrix for facial volume correction

BACKGROUND

Synthetic soft tissue fillers frequently used to restore facial volume do not provide a regenerative framework, limiting their sustained efficacy. Autologous fat transfer for facial rejuvenation supports tissue regeneration but has unpredictable outcomes depending on the quality of harvesting, processing, and implantation.

AIMS

Exploration of the pros and cons of available tissue fillers and the role of an injectable Allograft Adipose Matrix (AAM) for facial rejuvenation.

METHODS

The results of a literature review conducted by two clinicians with extensive experience in this field were discussed by a panel of dermatologists and surgeons who regularly treat patients with signs and symptoms of facial aging. A manuscript was prepared and reviewed by the panel taking into account the evidence and their clinical experience treating patients for facial rejuvenation.

RESULTS

Facial rejuvenation needs to address the volume deficiency and repositioning of ptotic soft tissues. Frequently used synthetic fillers are suitable candidates for improving the facial appearance of fine lines and for molding. A better understanding of facial volume loss has allowed the use of adipose fat cells for facial rejuvenation. The injectable AAM is readily available and provides a regenerative framework for sustainable results. Prospective clinical and randomized studies support the effective and safe use of AAM for facial rejuvenation.

CONCLUSION

AAM may offer an alternative to synthetic fillers and autologous fat implantation in the face without the cumbersome process of fat harvesting and processing. More robust studies are to confirm the positive results obtained in smaller studies using the soft tissue bio stimulatory injectable.

Current state of the art in fat grafting: paradigm shift in surgical techniques and refinements in cleft and craniofacial reconstruction

PURPOSE OF REVIEW

The purpose of this review is to provide an update on current practice and trends in fat graft surgery. The present review covers postoperative fat graft survival and phases, recipient bed and fat tissue enrichment issues, the spectrum of clinical applications in the cleft-craniofacial field, surgical techniques, and predictive factors for different outcomes.

RECENT FINDINGS

Current investigations have led to a better understanding of fat graft survival and postoperative clinical progress. Fat grafting has been successfully adopted in a broad spectrum of cleft-related, craniofacial contour-related, burn-related, and radiation-related indications. Many variations on harvesting, processing, and delivery techniques and the use of recipient-site preconditioning and cell-enriched methods to increase the efficiency of fat grafting have been described, but little consensus exists about which technique is optimal. The development of predictors for fat grafting-related outcomes can aid multidisciplinary teams in providing better preoperative counseling, selecting the most suitable candidates for treatment, and establishing patient-specific postoperative care profiles.

SUMMARY

The addition of modern fat graft surgery to the surgeon's toolbox revolutionized the delivery of surgical cleft and craniofacial care. Further investigation is necessary to assist surgeons in selecting the best candidates and optimal techniques.

Rhinoplasty Combined With Centrofacial Lipofilling to Optimize Facial Proportions

Background

The perceived appearance of the nose is influenced by its foundations (ie, malar areas, lip, and chin). The association of nasal hump and centrofacial volume deficiency is not uncommon.

Objectives

We evaluated and analyzed the role of centrofacial lipofilling simultaneously to rhinoplasty to sculpt facial proportions and shapes all in one procedure.

Methods

Volumes and placement of fat graft were determined preoperatively. Centrofacial microfat grafting was performed concomitantly to the rhinoplasty. Treated areas were malar, upper lip, pyriform aperture, and chin.

Results

From January 2016 to January 2019, concurrent lipofilling was performed in 23 rhinoplasties. Fat graft volumes ranged from 2 to 31 mL.

Conclusions

Centrofacial lipofilling is a simple and effective tool that can easily be associated with rhinoplasty techniques to optimize the results and may even influence the procedure towards a more conservative approach.

Level of Evidence: 4

Temporal Fat Grafting in Children With Craniofacial Anomalies

BACKGROUND

Fat grafting is a common adjunct procedure used to treat temporal fat hollowing in children with craniofacial anomalies. The goal of this study was to assess the surgical and aesthetic outcomes of this procedure.

METHODS

We retrospectively reviewed patients who underwent temporal fat grafting at a single tertiary pediatric craniofacial center. The surgical outcome was assessed based on intraoperativeand 30-day postoperative complication rates. The aesthetic outcome was assessed by 3 independent investigators using a 3-point grading scale for preoperative temporal hollowing severity (1 = mild, 2 = moderate, 3 = severe) and a 5-point scale for postoperative improvement (0 = no, 1 = mild, 2 = moderate, 3 = significant, and 4 = complete improvement).

RESULTS

Forty-three patients met inclusion criteria. Twenty-seven (63%) were male, 39 (91%) had a history of craniosynostosis, and 18 (42%) had associated syndromes. The mean age at fat grafting was 9.9 years (2.7-20.4, SD = 5.5) with an average follow-up time of 1.6 years (0-5.8, SD = 1.8). The average volume of fat grafted was 8.6 mL (0-30, SD = 5.9) to the right temporal region and 8.6 mL (0-30, SD = 5.8) to the left. There were no intraoperative or postoperative complications. The mean improvement score was 2.9 (1-4, SD = 0.7), demonstrating that most patients experienced moderate to significant improvement. Multiple linear regression analysis demonstrated that syndromic status had a negative impact on the aesthetic outcome (P < 0.001).

CONCLUSIONS

These findings demonstrate that fat grafting is an effective method to treat temporal hollowing in children with craniofacial anomalies with no perioperative complications.

The Impact of N-Acetylcysteine on Autologous Fat Graft: First-in-Human Pilot Study

BACKGROUND

Our goal was to determine whether N-acetylcysteine (NAC) administered to the tumescent solution can reduce oxidative stress and increase autologous fat graft (AFG) viability.

METHODS

The study included 15 women with a mean age of 31.8 years (range 23-39 years) who underwent breast asymmetry correction with AFG harvested from both thighs. One thigh was infiltrated with a standard tumescent fluid (control graft) and other with a NAC-enriched tumescent fluid (NAC-treated graft). Each participant had breast MRI imaging before and 6 months after the procedure. Also, adipose tissue samples from each graft were subjected to biochemical analysis, flow cytometric assay and qRT-PCR to determine the markers of oxidative stress, angiogenesis and adipogenesis.

RESULTS

Concentration and activity of superoxide dismutase in the NAC-treated grafts turned out to be significantly higher than in the control grafts, in both fresh (p = 0.041 and p = 0.023, respectively) and frozen samples (p = 0.004 and p = 0.003, respectively). The level of nitric oxide in frozen samples from the control grafts was significantly higher than in the NAC-treated grafts (p = 0.009). iNOS was the only qRT-PCR target showing significant intergroup differences, with higher transcription levels observed in the control grafts (p = 0.027). Breast volumetric analysis demonstrated that the NAC-treated group had a 12.19% lower resorption rate than the control group, although it was found to be statistically insignificant (p = 0.149). No postoperative complications were observed during a 6-month follow-up.

CONCLUSIONS

Some results of this study are promising. Further studies on larger groups are needed to determine NAC impact on AFG.

TRIAL REGISTRY NAME

The Impact of N-Acetylcysteine on Volumetric Retention of Autologous Fat Graft for Breast Asymmetry Correction.

REGISTRATION IDENTIFICATION NUMBER

NCT03197103. URL FOR THE REGISTRY: https://clinicaltrials.gov/ct2/show/NCT03197103?term=acetylcysteine&rank=6 LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Safety and Regulation of Fat Grafting

Today, fat grafting has wide applicability across plastic surgery disciplines, including both aesthetic and reconstructive procedures. However, much controversy has surrounded adipose tissue transfer throughout the 20th century, necessitating extensive research to improve the fat grafting process and to better understand its associated complications and benefits. Initial concerns included the technical difficulties of properly handling and processing adipose to ensure adequate outcomes. As these issues were addressed, more modern concerns were raised by the U.S Food and Drug Administration and the general scientific community regarding the oncological potential of adipose tissue and its potential interference with breast cancer screenings. Today, many formalized clinical studies have evidenced the safety of fat grafting, allowing the procedure to gain widespread popularity and opening avenues for future applications.

Molecular Characterization of Lipoaspirates Used in Regenerative Head and Neck Surgery

Importance

Adipose-derived mesenchymal stem cells (ASCs) have been used commonly in regenerative medicine and increasingly for head and neck surgical procedures. Lipoaspiration with centrifugation is purported to be a mild method for the extraction of ASCs used for autologous transplants to restore tissue defects or induce wound healing. The content of ASCs, their paracrine potential, and cellular potential in wound healing have not been explored for this method to our knowledge.

Objective

To evaluate the characteristics of lipoaspirates used in reconstructive head and neck surgical procedures with respect to wound healing.

Design, Setting, and Participants

This case series study included 15 patients who received autologous fat injections in the head and neck during surgical procedures at a tertiary referral center. The study was performed from October 2017 to November 2018, and data were analyzed from October 2017 to February 2019.

Main Outcomes and Measures

Excessive material of lipoaspirates from subcutaneous abdominal fatty tissue was examined. Cellular composition was analyzed using immunohistochemistry (IHC) and flow cytometry, and functionality was assessed through adipose, osteous, and chondral differentiation in vitro. Supernatants were tested for paracrine ASC functions in fibroblast wound-healing assays. Enzyme-linked immunosorbent assay measurement of tumor necrosis factor (TNF), vascular endothelial growth factor (VEGF), stromal-derived factor 1α (SDF-1α), and transforming growth factor β3 (TGF-β3) was performed.

Results

Among the 15 study patients (8 [53.3%] male; mean [SD] age at the time of surgery, 63.0 [2.8] years), the stromal vascular fraction (mean [SE], 53.3% [4.2%]) represented the largest fraction within the native lipoaspirates. The cultivated cells were positive for CD73 (mean [SE], 99.90% [0.07%]), CD90 (99.40% [0.32%]), and CD105 (88.54% [2.74%]); negative for CD34 (2.70% [0.45%]) and CD45 (1.74% [0.28%]) in flow cytometry; and negative for CD14 (10.56 [2.81] per 300 IHC score) and HLA-DR (6.89 [2.97] per 300 IHC score) in IHC staining; they differentiated into osteoblasts, adipocytes, and chondrocytes. The cultivated cells showed high expression of CD44 (mean [SE], 99.78% [0.08%]) and CD273 (82.56% [5.83%]). The supernatants were negative for TNF (not detectable) and SDF-1α (not detectable) and were positive for VEGF (mean [SE], 526.74 [149.84] pg/mL for explant supernatants; 528.26 [131.79] pg/106 per day for cell culture supernatants) and TGF-β3 (mean [SE], 22.79 [3.49] pg/mL for explant supernatants; 7.97 [3.15] pg/106 per day for cell culture supernatants). Compared with control (25% or 50% mesenchymal stem cell medium), fibroblasts treated with ASC supernatant healed the scratch-induced wound faster (mean [SE]: control, 1.000 [0.160]; explant supernatant, 1.369 [0.070]; and passage 6 supernatant, 1.492 [0.094]).

Conclusions and Relevance

The cells fulfilled the international accepted criteria for mesenchymal stem cells. The lipoaspirates contained ASCs that had the potential to multidifferentiate with proliferative and immune-modulating properties. The cytokine profile of the isolated ASCs had wound healing-promoting features. Lipoaspirates may have a regenerative potential and an application in head and neck surgery.

Level of Evidence

NA.

Isolated Fat Grafting for Reconstruction of Lower Face Volumetric Asymmetry in Skeletally Immature Patients: A Clinical Outcome Study

BACKGROUND

The purpose of this study was to assess the objective and subjective outcomes of lower face volumetric (contour) asymmetry correction with isolated fat grafting in skeletally immature patients.

METHODS

A prospective analysis was conducted of skeletally immature patients (n = 73) with craniofacial microsomia and Parry-Romberg syndrome who underwent isolated fat grafting (with no previous or concomitant bone surgery) using anatomical surgical principles (facial subunits and fat compartments) for the reconstruction of lower face volumetric asymmetry. Objective ultrasound and photogrammetric lower face symmetry analyses were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment of blinded surgical professionals and laypersons was also obtained to grade the subjective lower face symmetry.

RESULTS

There were significant (all P < 0.05) postoperative objective and subjective lower face symmetry enhancements (preoperative < postoperative) after isolated fat grafting, with no differences (all P > 0.05) between 3 versus 12 months' postoperative comparisons.

CONCLUSIONS

Growing patients with unilateral lower face volumetric asymmetries presented with improvement of objective and subjective symmetry after a single isolated fat grafting procedure.

Autologous Fat Graft for Soft Tissue Camouflage in Craniofacial Microsomia

INTRODUCTION

In India, a large majority of patients with craniofacial microsomia are unable to undergo complex reconstructions owing to unaffordability, lack of access to good craniofacial centers, or reluctance of parents to accept the surgical risk. There is also considerable social stigma attached to the resultant facial scars of surgery, especially in a girl child. Hence, we have explored autologous fat graft transfer as a "stand-alone" reconstructive option for soft tissue camouflage and aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II.

MATERIALS AND METHODS

Twelve patients who were seeking aesthetic correction of facial deformity in unilateral craniofacial microsomia of Pruzansky-Kaban Grades I and II, and who had adequate fat in the preferred donor sites of lower abdomen and antero-medial thighs, were selected. Patients with Grade III deformity, facial palsy, and previous skeletal surgeries were excluded. Autologous fat harvesting was done with the standardized Coleman's technique and injected after decantation. Volumetric augmentation was assessed by clinical comparison with normal side for facial symmetry, skin pinch thickness at four reference points, and by two-dimensional analysis of pre- and postoperative standardized photographs at periodic intervals.

RESULTS AND ANALYSIS

Eleven of our patients were female and one was a male (N = 12). In each session, 20-40mL (mean 28.75 ± standard deviation [SD] 5.69) fat was aspirated and 12-35mL (mean 23.67 ± SD 6.07) fat was injected. The average operating time was 35min (mean 32.91 ± SD 4.05). Majority of our patients needed three sessions (mean 2.8 ± SD 1.03) of serial fat injections to achieve bilateral facial symmetry. Increase in skin pinch thickness was 6.4167 ± 1.31 mm. The mean patient satisfaction score was 8.83 ± SD .717.

CONCLUSION

Based on our results, we conclude that autologous fat transfer, when used for soft tissue camouflage, is a versatile, easy, effective, and inexpensive method for obtaining consistent long-term aesthetic goals in mild to moderate cases of craniofacial microsomia.

Autologous Fat Grafting for Craniofacial Reconstruction in Oncologic Patients

Due to the anatomical and functional complexity of the region, craniofacial tumor removal requires some of the most challenging surgical approaches, often complemented with advanced chemo-radiotherapy techniques. However, these modern therapies often lead to sequelae that can drastically reduce the quality of life for the surviving patients. Recent advances in the field of regenerative medicine opened new avenues for craniofacial reconstruction following head and neck cancer treatment. One of the most promising recent strategies relies on the use of autologous fat transplant. In this mini review, we briefly present some of the fat’s biological properties that make it an ideal tissue for craniofacial reconstruction following cancer treatment. We then outline the recent advances that led to a better understanding of the detailed anatomy of the craniofacial fat depots. Furthermore, we provide a succinct review of the methods used for fat harvesting, processing and engrafting in the craniofacial area after head and neck tumor removal, discussing their main applications, advantages and limitations.

Autologous Fat Harvest and Preparation for Optimal Predictable Outcomes

Best practices in fat transfer to the face focus on tissue harvest and processing techniques. This article discusses the role of adipose-derived mesenchymal stem cells (MSCs) in mitigating tissue loss in grafting. Discrepancies among common practice and recent study results have propagated uncertainty with long-term results. Fortunately, recent increases in the understanding of these MSCs are leading providers to identify statistically more favorable tissue donor sites, harvest technique, and preparation methods to increase their concentration in transferred tissue. Future studies are needed to support or confound the long-term effects of MSC transfer on facial fat grafting.

Anatomical Fat Grafting for Reconstruction of Frontotemporal Contour Deformities After Neurosurgical and Craniofacial Surgical Interventions: A Symmetry Outcome Study

BACKGROUND

Fat grafting has been described as an option to repair frontotemporal contour deformities (volumetric deficiency of bone and/or soft tissues) after neurosurgical/craniofacial surgical interventions. However, technical surgical descriptions have varied, with reports describing the bolus fat injection or the classical multilayer injection, but with no detailed descriptions concerning how and where the fat should be grafted. The purpose of this study was to assess the frontotemporal symmetry outcomes after a single fat-grafting procedure for postoperative frontotemporal contour deformity reconstructions using the anatomical fat-grafting approach.

METHODS

A prospective analysis was conducted of consecutive patients (n = 106) who underwent anatomical fat grafting (Coleman's structural fat grafting technique using anatomical facial subunit and fat compartment principles) to reconstruct frontotemporal contour deformities after neurosurgical/craniofacial surgical interventions. A subjective assessment by a panel of external surgical professionals and laypersons was obtained to grade the frontotemporal symmetry. Objective ultrasound symmetry assessment was blindly performed preoperatively and at 3- and 12-month follow-up.

RESULTS

There were significant (all P  <  0.05) postoperative subjective and objective frontotemporal symmetry enhancements (preoperative < postoperative) after anatomical fat grafting, with no differences (all P > 0.05) between the 3- and 12-month postoperative comparisons. Thirty-seven percent of patients required an additional fat grafting session for residual asymmetry after 12 months of follow-up.

CONCLUSIONS

Patients with frontotemporal contour deformities presented improved subjective and objective frontotemporal symmetry after an anatomical fat grafting session.

Identifying Three-Dimensional Facial Fluctuating Asymmetry in Normal Pediatric Individuals: A Panel Assessment Outcome Study of Clinicians and Observers

This study measured three-dimensional facial fluctuating asymmetry in 600 normal and healthy Taiwanese individuals (6 to 12 years old) and assessed the perceptions of increasing levels of facial fluctuating asymmetric severity by using a panel composed of 20 clinicians (surgical professionals), as well as 20 adult and 40 pre-adolescent observers. On average, this normal cohort presented a facial fluctuating asymmetry of 0.96 ± 0.52 mm, with 0.52 ± 0.05, 0.67 ± 0.09, 1.01 ± 0.10, and 1.71 ± 0.36 mm for levels I, II, III, and IV of severity, respectively. For all categories of raters, significant differences in the average symmetry-asymmetry scale values were observed, with level I < level II < level III = level IV (all p < 0.01, except for level III vs. IV comparisons with p > 0.05). For level I, pre-adolescent observers presented a significantly (p < 0.05) higher symmetry-asymmetry scale value than adult observers, with no significant (all p > 0.05) differences for other comparisons. For overall facial asymmetry and levels II, III, and IV, no significant (all p > 0.05) differences were observed. This study reveals that the normal pediatric face is asymmetric and the panel assessment of facial fluctuating asymmetry was influenced by the level of severity and the category of raters and contributes to the literature by revealing that pre-adolescent raters present a similar or higher perception of facial asymmetry than adult raters.

Fat Grafting in Managing Craniofacial Deformities

BACKGROUND

The successful correction of craniofacial contour deformities remains a major challenge in plastic surgery. This article reviews important concepts and strategies for craniofacial fat grafting and presents a SOBRAPAR Hospital algorithm focused on achieving craniofacial contour symmetry as early as possible without compromising function.

METHODS

Principle-based methods (i.e., anatomical facial fat compartments, fluid accommodation model, multistage site-specific craniofacial fat grafting, and structural fat-grafting technique) were itemized into an algorithm to aid in planning and selecting the best surgical approach (i.e., bone and/or soft tissue procedures) in order to obtain craniofacial contour symmetry.

RESULTS

The treatment plan and choice of surgical technique implemented to address bone and/or or soft tissue deformities were determined by specific diagnosis, patient age at presentation, and functional status. Bony reconstruction in skeletally immature patients is reserved solely for those patients with functional issues.

CONCLUSION

By adopting principle-based methods and fat compartment theory, we are able to achieve craniofacial contour symmetry and aesthetically pleasing outcomes without compromising function.

Enhancing Facelift With Simultaneous Submalar Implant Augmentation

BACKGROUND

The midface is particularly prone to the senescent changes of soft tissue ptosis and volume loss, which in individuals with aging or low adiposity can manifest as submalar hollowing. Facelift alone in those with submalar hollowing inadequately addresses the volume loss and may result in a gaunt appearance postoperatively. Submalar implant augmentation is a powerful tool for permanent midface volume restoration for a more youthful and natural contour, as opposed to soft tissue fillers that diminish over time. When performed together, submalar augmentation and facelift synergistically enhance facial rejuvenation results.

OBJECTIVES

Determine the long-term safety and efficacy of submalar implant augmentation as an adjunct to facelift.

METHODS

Retrospective review evaluating results and complications in all consecutive patients who had submalar implant augmentation with SMAS-plication facelift in a single surgeon private practice setting from January 1, 1991, to December 31, 2017.

RESULTS

Forty-eight patients underwent submalar augmentation with simultaneous facelift with an overall satisfaction rate of 95.7%. Complications included 2.1%transient infraorbital hypoesthesia, 1.1% prolonged swelling, and 1.1% capsular contraction that required a minor adjustment under local anesthesia. No infection, implant migration, or extrusion or facial nerve injury occurred.

CONCLUSIONS

Submalar implant augmentation is a safe and effective means of enhancing facelift results through midface volume restoration, subperiosteal release, and improved soft tissue suspension in a more favorable vector. Submalar implant augmentation performed simultaneously with facelift may be an attractive alternative to repeated soft tissue filler or fat injections for patients with submalar hollowing who are interested in facial rejuvenation surgery.